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1.  Predictors of Bisexual Behaviour among MSM Attending Intervention Sites May Help in Prevention Interventions for This Bridge to the Heterosexual Epidemic in India: Data from HIV Sentinel Surveillance 
PLoS ONE  2014;9(9):e107439.
Indian cultural tradition demanding marriage, many MSM howsoever they self-identify are likely to be married or have sex with women. To consolidate India's HIV prevention gains, it is important to understand and address the interaction between the MSM and heterosexual epidemics in India and create specific interventions for bisexual MSM. The challenge is to identify and intervene this hard to reach population. Data from HIV Sentinel Surveillance 2011 among MSM in four Indian states were analyzed to assess predictors and prevalence of bisexual behaviour in MSM.
Between March-May 2011, 4682 men (15–49 years) who had anal/oral sex with a male partner in the past month, attending intervention sites and consenting for an un-linked anonymous survey answered an 11- item questionnaire and provided blood for HIV test by finger stick at 19 designated surveillance sites.
Of 4682 MSM tested overall, 5% were illiterate, 51% reported only receptive anal intercourse, 21% only penetrative and 28% both. 36% MSM had ever received money for sex. Overall 6.8% were HIV infected. 44% MSM were bisexual in the last six months. On multivariate analysis, ‘being bisexual’ was found to be independently associated with ‘older age’: 26–30 years [AOR = 3.1, 95% CI(2.7, 3.7)], >30 years [AOR = 6.5, 95% CI(5.5, 7.7)]; ‘reporting penetrative behaviour alone’ with other men [AOR = 5.8, 95% CI(4.8, 7.0), p<0.01] and ‘reporting both penetrative and receptive behaviour’ [AOR = 2.7, 95% CI(2.3, 3.1) p<0.01]. Those who both paid and received money for sex [AOR = 0.49, 95% CI (0.38, 0.62)] were significantly less likely to be bisexual.
A substantial proportion of men receiving services from Targeted Intervention programs are bisexual and the easy opportunity for intervention in this setting should be capitalised upon. Focusing on older MSM, as well as MSM who show penetrative behaviour with other men, could help in reaching this population.
PMCID: PMC4161389  PMID: 25211511
2.  Heterosexual Anal Sex among Female Sex Workers in High HIV Prevalence States of India: Need for Comprehensive Intervention 
PLoS ONE  2014;9(2):e88858.
Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.
Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.
Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.
Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.
PMCID: PMC3930672  PMID: 24586416
3.  Initial Virologic Response and HIV Drug Resistance Among HIV-Infected Individuals Initiating First-line Antiretroviral Therapy at 2 Clinics in Chennai and Mumbai, India 
Human immunodeficiency virus drug resistance (HIVDR) in cohorts of patients initiating antiretroviral therapy (ART) at clinics in Chennai and Mumbai, India, was assessed following World Health Organization (WHO) guidelines. Twelve months after ART initiation, 75% and 64.6% of participants at the Chennai and Mumbai clinics, respectively, achieved viral load suppression of <1000 copies/mL (HIVDR prevention). HIVDR at initiation of ART (P <.05) and 12-month CD4 cell counts <200 cells/μL (P <.05) were associated with HIVDR at 12 months. HIVDR prevention exceeded WHO guidelines (≥70%) at the Chennai clinic but was below the target in Mumbai due to high rates of loss to follow-up. Findings highlight the need for defaulter tracing and scale-up of routine viral load testing to identify patients failing first-line ART.
PMCID: PMC3338312  PMID: 22544202
4.  CD4 estimating reagents in dry format are compatible with conventional flow cytometer; FACSCalibur for estimation of absolute CD4 count & percentages 
Background & objectives:
Reliable CD4 counts are important for successful implementation of antiretroviral treatment (ART). Availability of dry CD4 reagents can eliminate cold chain requirement reducing shipment and storage cost. An attempt was made in this study to validate the ReaPan and Rea T Count dry reagents developed by ReaMetrix against the original BD Biosciences liquid reagents.
Absolute counts and percentages of CD4, CD8 and CD3 + T cells obtained in 100 HIV infected individuals using the test and reference reagents were analyzed for correlation and agreement using Pearson's correlation and Bland Altman bias analysis. The stability of the reagents and of the stained samples was analyzed at ambient temperature and at 37°C.
The absolute CD4 + T cell count and percentages obtained using test and reference reagents showed correlation coefficients ranging from 833 to 981. A mean bias between dry and reference reagents ranged from 0.8 to 26.4. The ReaPan and Rea T Count reagents were stable up to one month at 37°C also. The samples stained with ReaPan reagents were stable at ambient temperature till day 7 whereas the samples stained with Rea T Count reagents were stable at ambient temperature and at 37°C for 10 days.
Interpretation & conclusions:
The ReaPan dry reagents can be used on existing FACSCalibur machines with additional training on Cell Quest Pro software without incurring any additional equipment cost and this can eliminate the requirement of cold chain during transport and on site storage. The stability of the stained samples has great clinical significance preventing redrawing of the blood samples from the patients.
PMCID: PMC3657859  PMID: 23563379
CD4; dry reagents; FACSCount; flow cytometry; HIV; quality control; stability
5.  Utility of the point of care CD4 analyzer, PIMA, to enumerate CD4 counts in the field settings in India 
In resource limited settings non-availability of CD4 count facility at the site could adversely affect the ART roll out programme. Point of care CD4 enumerating equipments can make the CD4 count available at the site of care and improve the patients’ management considerably. This study is aimed at determining the utility of a Point of Care PIMA CD4 analyzer (Alere, Germany) in the field settings in India.
The blood samples were collected from 1790 participants at 21 ART centers from different parts of the country and tested using PIMA and the reference methods (FACSCalibur, FACSCount and CyFlow SL3). The paired finger prick and venous blood samples from 175 participants were tested by the PIMA CD4 Analyzer and then by FACSCalibur.
The CD4 counts obtained by PIMA CD4 analyzer showed excellent correlation with the counts obtained by the reference methods; for venous blood the Pearson’s r was 0.921, p < 0.001 and the relative bias was 0.2% (range: -42 to 42%) and for finger prick samples, the Pearson’s r was 0.856 and the relative bias was −9.1% (range: -46% to 27%). For CD4 ranges; <250, 251–350, 351–500 and >500 cells/mm3, the differences in the median CD4 counts obtained by the reference method and the PIMA analyzer were not significant (P > 0.05) and the relative bias were low (−7 to 5.1%). The Intermachine comparison showed variation within the acceptable limit of%CV of 10%.
In the field settings, the POC PIMA CD4 analyzer gave CD4 counts comparable to the reference methods for all CD4 ranges. The POC equipment could identify the patients eligible for ART in 91% cases. Adequate training is necessary for finger prick sample collection for optimum results. Decentralization of CD4 testing by making the CD4 counts available at primary health centers, especially in remote areas with minimum or no infrastructure would reduce the missed visits and improve adherence of the patients.
PMCID: PMC3503578  PMID: 22998738
CD4+ T-cell count; HIV; Point-of-care; PIMA CD4 analyzer
7.  Stigmatizing attitudes and low levels of knowledge but high willingness to participate in HIV management: A community-based survey of pharmacies in Pune, India 
BMC Public Health  2010;10:517.
The World Health Organization (WHO) recommends that the role of pharmacists in low-income settings be expanded to address the increasing complexity of HIV antiretroviral (ARV) and co-infection drug regimens. However, in many such settings including in India, many pharmacists and pharmacy workers are often neither well trained nor aware of the intricacies of HIV treatment. The aims of our study were; to determine the availability of ARVs, provision of ARVs, knowledge about ARVs, attitudes towards HIV-infected persons and self-perceived need for training among community-based pharmacies in an urban area of India.
We performed a survey of randomly selected, community-based pharmacies located in Pune, India, in 2004-2005 to determine the availability of ARVs at these pharmacies, how they were providing ARVs and their self-perceived need for training. We also assessed knowledge, attitudes and perceptions on HIV and ARVs and factors associated with stocking ARVs.
Of 207 pharmacies included in the survey, 200 (96.6%) were single, private establishments. Seventy-three (35.3%) pharmacies stocked ARVs and 38 (18.4%) ordered ARVs upon request. The reported median number of ARV pills that patients bought at one time was 30, a two week supply of ARVs (range: 3-240 pills). Six (2.9%) pharmacy respondents reported selling non-allopathic medicines (i.e. Ayurvedic, homeopathy) for HIV. Ninety (44.2%) pharmacy respondents knew that ARVs cannot cure HIV, with those stocking ARVs being more likely to respond correctly (60.3% vs. 34.8%, p = 0.001). Respondents of pharmacies which stocked ARVs were also more likely to believe it was a professional obligation to provide medications to HIV-infected persons (91.8% vs. 78.8%, p = 0.007) but they were also more likely to believe that HIV-infected persons are unable to adhere to their medicines (79.5% vs. 40.9%, p < 0.01). Knowledge of the most common side effects of nevirapine, abnormal liver enzyme profile and skin rash, was reported correctly by 8 (3.9%) and 23 (11.1%) respondents, respectively. Seven (3.4%) respondents reported that they had received special training on HIV, 3 (1.5%) reported receipt of special training on ART and 167 (80.7%) reported that they believed that pharmacy staff should get special training on ART.
There is a high willingness to participate in HIV management among community-based pharmacies but there is a tremendous need for training on HIV therapies. Furthermore, stigmatizing attitudes towards HIV-infected persons persist and interventions to reduce stigma are needed, particularly among those that stock ARVs.
PMCID: PMC2939646  PMID: 20799948
8.  Short Communication: Neutralizing Antibody Responses in Recent Seroconverters with HIV-1 Subtype C Infections in India 
AIDS Research and Human Retroviruses  2008;24(9):1159-1166.
The longitudinal heterologous neutralization response against two HIV-1 subtype C isolates was studied in 33 ART-naive individuals recently infected with HIV-1 subtype C from India. Seven of 33 (21%) seroconverters demonstrated a consistent response against both isolates (65–100% neutralization), whereas the remaining 26 (79%) were nonresponders. Four of the seven responders demonstrated a neutralization response (>75% neutralization) within 2–3 months of infection and in the remaining three, the response was demonstrated between 22 and 38 months after infection. In the past, HIV vaccines targeted the V3 region for the development of neutralizing antibodies. However, recent studies have shown that anti-V3 antibodies are generated after HIV-1 infection, but are not effective in neutralizing virus. In this study, the V3 sequences of HIV-1 from seven responders were analyzed and compared with those from nonresponders. The V3 region sequences from early and late responders did show certain mutations that were not found in the nonresponders; however none of these mutations could explain the neutralization responses. This suggested that HIV-1 envelope regions other than the V3 domain may be involved in generating a neutralization response. This is the first report that describes the pattern of emergence and persistence of the heterologous neutralization response in recently HIV-1 subtype C-infected individuals from India and studies its association with sequence variation in the V3 region.
PMCID: PMC2928029  PMID: 18665801

Results 1-8 (8)